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December 2008 Calendar Template by zxg19147


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									Memphis and Shelby County Health Department (MSCHD) is a joint funded agency of County and City governments. Shelby County contains seven incorporated municipalities (e.g., Memphis, Arlington, Bartlett, Collierville, Germantown, Lakeland, and Millington) and several unincorporated areas. Shelby County is also the largest county in the State of Tennessee, both geographically (approximately 783 square miles) and in population (909,035).
With over 5,000 food establishments throughout Memphis and Shelby County, MSCHD is required by both Tennessee Department of Health and Tennessee Department of Agriculture annotated law to inspect facilities twice per year, and more often if critical sanitation violations have been cited or if there are food-borne outbreaks or food-borne complaint investigations.

                                                                               Implementation of a Pilot Program to Address Reliability of Environmental Sanitation
                                                                                        Inspections at Memphis and Shelby County Health Department                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             LOGO
                                                                                                                                                                                                                                                                                              Tyler Zerwekh, DrPH
                                                                                                                                                                                                                                                            Memphis and Shelby County Health Department
                                                                                                                                                                                                                                                                   Environmental Health Bureau

              BACKGROUND                                                                                                                                                                                            MATERIALS AND METHODS                                                                                                                                                                                                                             RESULTS
           •With over 5,000 food establishments throughout Memphis and Shelby County, MSCHD is required by                                                                                                                                                                                                                                                                                                                                                            •A total of 36 facilities were audited for 16 Environmentalists by 3 Lead Environmentalists
           both Tennessee Department of Health and Tennessee Department of Agriculture annotated law to                                                                                                             Program Goal                                                                                                                                                                                                                                      during the month of December 2008.
           inspect facilities twice per year, and more often if critical sanitation violations have been cited or if                                                                                                To implement an environmental sanitation inspection pilot program to address reliability, validity, and repeatability results for a
           there are food-borne outbreaks or food-borne complaint investigations.
                                                                                                                                                                                                                    comprehensive environmental sanitation program.                                                                                                                                                                                                   •Results demonstrated an average of 6.11 points lower score when the Lead Environmentalist
           •The association between environmental sanitation inspections and food-borne outbreaks in                                                                                                                Health Problem                                                                                                                                                                                                                                    performed an audit inspection after the environmentalist.
           communities has been documented extensively. With only seventeen environmentalists trained at                                                                                                            More than 54 billion meals are served at 844,000 commercial food establishments in the United States each year and nearly
           MSCHD to perform sanitation inspections on the 5,000+ facilities, it is not uncommon for an                                                                                                              half of all money spent on food is done so at food establishments. On a typical day, 44% of adults in the United States eat at a                                                                                                                  •The range of difference in sanitation inspection was from 20 points lower to 9 points higher
           environmentalist at MSCHD to perform over 700 inspections and follow-ups in one calendar year. The                                                                                                       restaurant. Approximately 40% of food-borne disease outbreaks reported to the Centers for Disease Control and Prevention are                                                                                                                      than the Environmentalist when the Lead Environmentalist performed the audit inspection
           sheer amount of inspections by environmentalists’ can lead to practices that ultimately compromise the                                                                                                   attributed to commercial food establishments. Preventing restaurant-associated food-borne disease outbreaks is an important                                                                                                                       immediately after the initial
           integrity of an individual inspection to satisfy the overall arching goal of total inspection completion.                                                                                                task of public health departments. Many times, sanitation inspections performed by public health departments at these food
           •During a recent audit investigation by the Tennessee Department of Health (TDH) on the MSCHD
                                                                                                                                                                                                                    establishments are not efficient or reliable when performed due to myriad reasons including, but not limited to, inspector
                                                                                                                                                                                                                    training level, workload, and type of facility inspected.                                                                                                                                                                                        Accidental Adversaries
           Environmental Sanitation division, it was documented that unannounced inspections by TDH
           immediately after a MSCHD inspection yielded an average difference score of 35 points with a range of                                                                                                    Outcome Objective
           one to five critical violations not documented by MSCHD environmentalists but observed and                                                                                                               The Memphis and Shelby County Health Department Environmental Sanitation program aimed to work with program
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Sa nita tion ma na ger invokes proc esses
           documented by TDH audit staff.                                                                                                                                                                           managers, lead environmentalists, and environmentalist to implement and execute a quality assurance pilot project that would                                                                                                                                                                                           to her liking tha t a llows f or
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      sa nita ria n to inspec t resta u ra nts in
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               a n inc omplete f a shion.
                                                                                                                                                                                                                    increase the repeatability and accuracy of environmental sanitation inspection scores at sanitation facilities.                                                                                                                                                                                                                         R
                                                                                                                                                                                                                    Tennessee Department of Health program audit determined a difference in 35 points (5 violations, 1 critical violation) on
              PURPOSE AND HYPOTHESIS                                                                                                                                                                                average of facilities audited after a MSCHD Environmentalist inspection
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Sa nita tion ma na gers
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  meets resta u ra nt
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  inspec tion q u ota s           B
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Elic it a rewa rd
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               pro gra m to en c o u ra ge
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 q u a n tity over q u a lity
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               in spec tio n s, pa y ra ises,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          D eprives Sa n ita ria n s o ppo rtu n ity
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             to diversif y workpla c e skills
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  while min imizes job
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 ma rketa bility . Crea tes
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          redu n da n c y in in spec tio n pro c ess
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                positive perf orma n c e

             •The significance of these findings listed in the Background has immediate environmental                                                                                                               METHODOLOGY:
             public health ramifications on Shelby County, TN, and its stakeholders. Inaccurate and
                                                                                                                                                                                                                    Event: Quality Assurance Pilot Program Planning
             underscored inspections increase the likelihood for a facility to continue practices and
             controls deemed unsanitary and unsafe. This can lead to an increased risk in unsafe food                                                                                                               Activities:                                                                                                                                                                                                                                                                                 No f orum/ a venue to
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                disc u ss or implement
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           c ha nge in inspec tion qua lity
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            CHART or            Continue to ra tiona lize
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     no c ha nge f rom
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                ma na gement to justif y
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      B                Sa n ita ria n s meet in spec tio n
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     or ef f ic ienc y                           medioc re inspec tion.
                                                                                                                                                                                                                    Meeting with Environmental Health Administrator and MSCHD Director of Health to present ideas for increasing repeatability                                                                                                                                                                                                                                                                     q u o ta s. Rec eive pro tec tio n f ro m
             and food handlers, which ultimately leads to a higher probability of food-borne and
             infectious disease transmission to facility patrons. This project will focus on the                                                                                                                    and accuracy of sanitation inspections (June 2008)                                                                                                                                                                                                                                                                      PICTURE              Inc rea ses inspec tion
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 q u a ntity whic h meets
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      ma na ger goa ls
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      ma n a ger f o r a dherin g to her
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       po lic ies a n d stu bbo rn n ess to
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      c ha n ge

             development and implementation of a sanitation pilot program that aims to increase the                                                                                                                 Meeting with MSCHD Environmental Sanitation program managers to unveil quality assurance pilot program sanitation
             accuracy and reliability of environmental sanitation inspections within the MSCHD                                                                                                                      inspection audit process and enlist support for the program (August 2008)                                                                                                                                                                                                                                          Sa nita ria ns oppose a ntiq u a ted a nd
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     redunda nt inspec tions tec hniques yet
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      keep ma na ger ha ppy by perf orming

             Environmental Sanitation Section.                                                                                                                                                                      Develop a timeline for integration, implementation, and execution of the pilot program (August 2008)                                                                                                                                                                                                            them in the ma nner they a re requested

             •Problem Statement: Implementation of an environmental sanitation inspection pilot                                                                                                                     Event: Workforce Development and Enhancements – Addressing personnel issues and the increase in expertise through
                                                                                                                                                                                                                    workforce development and technology
             program to address reliability, validity, and repeatability results for a comprehensive
             environmental sanitation program, which will provide accurate and representative                                                                                                                       Activities:                                                                                                                                                                                                                                       CONCLUSIONS
             sanitation scores of operator facilities to Shelby County stakeholders.                                                                                                                                Assess TDH audit criteria into pilot program training to ensure standardization (August 2008)
                                                                                                                                                                                                                    Conduct trainings for Lead Environmentalists to standardize audit inspections (September 2008)
                                                                                                                                                                                                                    Conduct trainings/re-trainings for Environmentalist to standardize sanitation inspections (September 2008)                                                                                                                                        The results demonstrate the pilot program was unsuccessful upon initial examination.
                                                                                                                                                                                                                    Reassign inspection “zones” to minimize inspection bias and confounding                                                                                                                                                                           However, it is worth noting that 20% (7 / 36) of the facilities audited did observe the
                                Changing Inspection                           Not Changing Inspection
                                                                                                                                                                                                                                                                                                                                                                                                                                                                      environmentalist scoring the facility lower than the audit procedure done by the Lead
                                Behavior                                      Behavior                                                                                                                              Event: Pilot Program Implementation                                                                                                                                                                                                               Environmentalist after the initial inspection. These results extrapolated demonstrate
          Benefits              •Increased quality of                         •Environmentalists continue                                                                                                           Activities:                                                                                                                                                                                                                                       there was value in implementation of the program, whether it was due to fear/concern
                                food consumption                              with minimal workload                                                                                                                 Environmentalists’ inspection of facilities                                                                                                                                                                                                       the environmentalist would be exposed for poor inspection methodology or because
                                                                                                                                                                                                                    Lead Environmentalists’ audit inspections of random facilities.                                                                                                                                                                                   there was an actual observed improvement in the sanitation inspection procedure.
                                •Decreased incidence                                                                                                                                                                Education to operators selected for audit inspections of pilot program
                                of food-borne         •Status quo                                                                                                                                                   Environmental Sanitation program manager analysis of audit inspections
                                illnesses and                                                                                                                                                                                                                                                                                                                                                                                                                         While the results were not favorable, it is worth noting this was the initial audit follow-
                                outbreaks                                                                                                                                                                                                                                                                                                                                                                                                                             up analysis for this pilot program and hopefully future audits will demonstrate more
                                                      •Inspection quotas are met                                                                                                                                                                                                                                                                                                                                                                                      frequent and improved reliability and repeatability in environmentalists’ scores and
                                •Efficient inspection                                                                                                                                                                                                                                                                                                                                                                                                                 Lead Environmentalists audits. Future steps and next directions include: 1) continued
                                process                                                                                                                                                                                                                                                                                                                       Shifting the Burden: Interventions
                                                                                                                                                                Shifting the Burden                                                                                                                                                                                                                                                                                   audit inspections to further underscore the importance of proper sanitation inspections,
                                                                                                                                                                                                                                                                                                                                                                                                                                                                      2) refresher and additional trainings for environmentalists who continue score
                                •Additional                                                                                                                                                Quick Fix: Time                                                                                                                                    1.     Quality inspections                                                                                              inspections higher than audit follow-ups, and 3) disciplinary action for
                                                                                                                                                                                         Spent and Resources                                                                                                                                                                                               Quick Fix -
                                encouragement and                                                                                                                                                                                                                                                                                                    ultimately increase
                                                                                                                                                                                                                                                                                                                                                     efficiency while decreasing                         Time Spent and                                               environmentalists who continue to underscore sanitation inspections.
                                acknowledgement by                                                                                                                                                                                                                                                                                                   time spent and resources
                                management and
                                                                                                                                                                                                                                                                                                                                                     Better trained inspectors
                                                                                                                                                                                                                                                                                                                                                                                                            and used                                         ???
                                community                                                                                                                         Symptom
                                                                                                                                                                                                 B                                                                                                 Problem Symptom
                                                                                                                                                                                                                                                                                                                                                     understand and implement
                                                                                                                                                                                                                                                                                                                                                     quality inspections while
                                                                                                                                                                                                                                                                                                                                                     maintaining quality                                                           1
          Costs                 •More work on behalf •Increased food-borne illnesses                                                                                                                                                                                                                                                                 assurance integrity and

                                of environmentalists                                                                                                                                                                    Side Effects: Failing t o
                                                                                                                                                                                                                                                                                                                                                     quota standards.                                                                X                   3
                                                                                                                                                                                            Poor quality of
                                                                                                                                                                                                                        meet monthly inspect
                                                                                                                                                                                                                          quotas and ‘c utting
                                                                                                                                                                                                                                                                                                Quick                                         3.     Cannot implement the                                 Poor Quality of
                                                      •Vicious cycles on behalf of                                                                                                             Sanitation
                                                                                                                                                                                                                            corners’ during
                                                                                                                                                                                                                         inspection process to                                                  Fixes                                                quick fix to build…creates                              Sanitation                              Side Effect —
                                                                                                                                                                                           Inspections and              meet their quota at t  he
                                                                                                                                                                                           Pressure to Meet                   last minute                                                                                                                                                              Inspections & Failure
                                •More interaction     environmentalists performing                                                                                                              Quotas
                                                                                                                                                                                                                                                                                                                                                     vicious cycles.                                      To meet inspec.                R
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         For more information, contact:
                                (good or bad) and     inspections                                                                                                                                                                                                                                               Long Term

                                perception of                                                                                                                      Cause                         B                                Side Effects          CHART or                                                Solutions                                                                      CHART or                                                                                                      Tyler Zerwekh, DrPH
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  Memphis and Shelby County Health department
                                                                                                                                                                 Correcting                                                       Undermining
                                accusations / unfair  •Environmentalists don’t have
                                practices to          to change behavior
                                                                                                                                                                  Process                                                          Efforts to
                                                                                                                                                                                                                                                        PICTURE                                                                                                                                PICTURE X 2         B
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            814 Jefferson Ave., 502H
                                                                                                                                                                                        Capacity development.                     Fundamental                                                 Time                                                                                                                                                                                                            Memphis, TN 38105
                                restaurants                                                                                                                                                  For training
                                                                                                                                                                                          Betters Inspectors
                                                      •No long term improvements in                                                                                                         meet Quotas
                                                                                                                                                                                                                                                                                                                                                               Desired Vision                      Long Term Solution
                                                                                                                                                                                                                                                                                                                                                                                                 Capacity development
                                •More work for audits inspection process                                                                                                                                                                                                                                                                                                 2                             for training.
                                                                                                                                                                                                                                                                                                                                                                                                    Better inspectors
                                quality assurance                                                                                                                                                                                                                                                                                                                                                      meet quotas
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  printed by
                                inspections by lead   •No opportunities for additional
                                staff                 training that is meaningful                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 

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